Opinions sought...I have been having pain along the lateral side of my left foot often. I do have a little bit of a "tailor's bunion" there, but the pain/soreness continues up the side of the foot, but not to the heel, and seems to involve the bone along the outside of the mid-foot.

Sometimes I'll massage the area, or roll my foot back and forth on a foam roll, which helps somewhat.

I also suspect my store bought shoes as part of the problem. I am finally starting on making another pair of shoes (after being on shoemaking hiatus for almost a year due to hand surgery, family illness, etc., and then, off course, revising my lasts). The lasts are designed to acommodate orthotics (I have high arches and somewhat inflexible feet).

This business about the running shoes having too much support brings up this question: how do you make an orthotic that's supportive, but not so supportive that it it interferes with the way the foot should work and causes other problems?

Jenny,
I think the lateral arch is very important to have springiness and it supports the medial arch as well.

From the cuboid bone in the lateral midfoot[the keystone of the midfoot arch with the 3 cuneiform bones]to the distal head of the 5th metatarsal head is the lateral arch.The tailors bunion is a lateral migration of the 5th metatarsal bone.Along the outside of the foot is a lateral band of the plantar fascia that sort of rolls over sideways.

High arched feet usually are a rigid foot type.

Remember this, your feet should pronate from heel strike through midstance and supinate from heel lift through the toe off propulsive phase in the gait cycle.Approx.60%of energy is loading the big toe joint and 40% engaged in loading the 4 lesser toes.

The foot orthoses is designed by blocking excessive unwanted pronatory motion in the rear and midfoot, so the foot will supinate at midstance.This is achieved by a rear foot medial wedging designed in the heel cup of the device or a medial wedge under the heel bone at the bottom of the orthotic.I do believe that 90% of balancing the forefoot is achieved in the rearfoot.

All 5 metatarsals plantarflex at midstance to toe off and all 5 toes dorsiflex.This is a brief description of how the foot should function.

Now consider the etiology of a fallen lateral arch and the tailors bunion.Like the 1st metatarsal bone the 5th metatarsal both have available pronatory and supinatory range of motion.Soft connective tissue like ligaments and fascia allow movements and hold skeletal bones intact.When your heel hits the ground and rolls down the lateral column with a plantarflexed 5th metatarsal bone the outside arch and 5th metatarsal devoid of its spinginess cannot dorsiflex and absorb your weight and the outside of the foot puts excessive strain on the connective tissues,the lateral slip of the plantar fascia gets strained.

Additionally through myo-fascial connections throughout the leg,the peroneal musles brevis and longus which are primary evertors,anterior tibialus muscle,lateral hamstrings and the ileo tibial band into the fascia latae to the ilium are all kinetically involved.

So the medial wedge and lateral arch support will help.Now what about the weight moving across the metatarsal heads till all 5 metatarsals are on the ground when the foot should supinate?What are the relavent bio-mechanics in the 1st MPJ[BIG TOE JOINT?

Foot orthotics that are supportive and not too supportive ideally should enable the wearer to walk in a natural manner without any abnormal compensation in the entire lower extremity.

Given the variable of the shoe ,the fit of the orthotic in the shoe a lifetime of abnormal compensation,a persons sensitivities with materials and many other variables,there exist a great need for orthopedic shoe specialist in the world.

The other possible solutions probably can be in physical therapy,Yoga ,tai chi,a good osteopath or in areas of myo fascia or structual integration.

Jenny,
Thanks for the article on the effects of runners on the other joints of the lower body. This research is fairly new. They have only recently been able to take these measurements.
Nike is doing a lot of research with their Nike Free 5.0 that challenges long held beliefs on biomechanics of the foot a lower leg. The shoe is designed to have 50% of the support of a traditional shoe. The idea came from the Huarache sandal that Rick posted earlier. There were a lot of upset Pedorthists at the last conference I attended that showed the negative effects of traditional runner and orthotic principles. I'm always willing to question what I've been taught
Concerning your lateral foot pain...
I would follow Brendan's advice... A physiotherapist would be able to determine if you have a jammed up cuboid bone. I would also check to see if your Talus is anteriorly subluxed (shifted forward) Both are quite common with your foot type and would cause the symptoms you describe.
I would leave your orthotics alone until you get your foot looked at. The mechanics of your foot will change radically after having them mobilized.

Realized I didn't respond to all questions. I'm not sure what my forefoot posting is (or even exactly what that means). I'm not wearing orthotics now, because I still don't have comfortable shoes that will accomodate them. I'm working on making perhaps my 10th pair of shoes right now, and these should do the trick, but I say that every time! (I have other weird feet sensitivities that make this a difficult goal to achieve.)

Fred has examined my feet at HCC meetings, and might know the answer to the forefoot posting question, although it was a couple years ago.

What is a physiotherapist--is that the same thing as a physical therapist? If not, does health insurance normally cover that kind of specialist?

Jenny,
Physiotherapist and physical therapist are the same welltrained healthcare professionals.To the best of my knowledge they can clinically ascess or evaluate musculo-skeletal issues.
You would get some medical coverage for an orthopedist,podiatrist and probably for an osteopath.A sports medicine doc or clinic is a good choice and with xrays you can see the bones and joints.That clinic could refer you to physical therapy and again you should be covered by your insurance.

I think you need someone in your vicinity to evaluate your feet,your footwear and your orthotics.Perhaps Michaelangelo`s Foot Comfort and Pedorthic Shoppe in Norridge,Il.
Michaelangelo Scafidi,Cped.8344 W. Lawrence,tel.#708/453-4900.He will require a prescription for any work or services.You will have to make an app`t.They are a shoe store and Michael can refer you to a physician for the Rx if needed.

If you'll excuse me, but I have a bit of a quandry, and I'd like some feedback.

The customer receiving the current 110% of my attention has very flat feet. And in spite of the fact that I've reduced the throat measure by an additional 1/2" over usual when creating his top patterns, which usually suffices to bring the break down upon the instep of flat feet , and the fact that the last is right on for measurements, he's still swimming in them.

He commented on the arch being more pronounced than he was accustomed to, and I said that personally I felt it should be, and intend to make little change in that. But I don't know why it should be soo loose over his instep.

This is not the first I've had this problem with.
WHat other adjustments to my pattern could I make?

This same customer has other issues regarding the LOMA, the Line of Muscular Action, which runs parallel to the outside line of the foot, and inward to the point between the big toe and next. (Please correct me if I'm wrong.)

While the last sits well between the ouside points on his imprint for ball width, and the toe of the last is centered on the LOMA line, in the fitter he still lays close up against the lateral side of the fitter, and seems to pull away from the medial side.

paul it sounds like he has a collaps medium arch. What this means is, that although he will imprint as a flat foot, his side tissues displace as the wieght of his body falls onto his arch.

You can examine this theory by having him lay on a couch like apperatus and having his feet proped up on the arm of the couch. alingn his tarsal bones so they are striaght with his tibial bone. his foot perpendicular to the floor.

If his arch relaxes in further into a more foot arch shape than when he is taking a pedi, than it is true.

He is correct though, someone who is not accustomed to an arch correction or arch hug in the area, will find this uncomfortable. I will venture to say that even when recomending student to make integrated arch support lasts, I tell them if it is a first time customer, fit the planter surface of the last flat, and make the boot or shoe deeper and then add orthotics to the footwear. Re-instating an arch should be done gradually.

However, I am looking at this problem from a hand lastmakers point of view.

It is possible that reducing the cone a bit, clipping the last a bit more and curving the heel curve a bit more may solve your fit problems. But with out actually seeing what you are making I am pulling that information out of the air based on what you said.

Paul I would like to see those pictures.
I have a few ideas and questions;
does you client stand or walk knock kneed?
are his feet positioned "out" unusually when he walks? (duck feet)
does he have any medical conditions that you know of such as nerve damage, vascular disease, or diabetes?
does he have a callous on the bottom or side of his medial arch?
do his shoes usually collapse or roll off the medial edge after wearing the sole thin on the medial side?
if he has been wearing shoes that are collapsed in this fashion it will be an uncomfortable extreme of correction to even go into a neutral alignment.

Paul,
Has your client ever sought any intervention for his flat foot condition?

It sounds like a flexible flat foot.Perhaps the foot or feet are splaying on weight bearing.Generally this foot cannot resupinate at heel lift.The medial arch will collapse and the foot will continue into pronatory motion in midstance and toe off phases in gait.

I suggest that you look at client standing barefoot from behind.I suspect you will see eversion in the achilles tendon.Supporting the medial heel,specifically the calcaneous[heel bone]with approx.up to 8 degrees heel wedge inside your "fitter" will change everything for your client.8 degrees equals 1/4".I think this will change the instep.The medial wedge should be firm vs anything soft.55 or 65 durometer Soleflex is good,depending on persons weight.

Try measuring arch length and foot length sitting and standing.See how the foot splays,collapsing in the medial arch and the forefoot abducting,laterally in weight bearing vs.non weight bearing.

Jask made some valuable comments.You may be dealing with a medical condition that needs your attention.And photos will help.Gait videos barefoot even better for evaluation.

What does SOMA mean?It sounds like the lateral peroneous longus and brevis may be a tendonitis.And I would be concerned of the weakness of the posterior tibialis muscle/tendon as that is a common problem.Post.Tib.is the main inverter and it is weak or dysfunctional.

The idea is that heel control is about 90% of foot control enabling the foot to resupinate at midstance to heel lift in gait.It is important for the 1st mpj[metatarsal phalangeal joint]to plantarflex at heel lift to toe off in gait and the forefoot is balanced where about 60% of loading is on the big toe and 40% across the lesser toes.

Bear this in mind,the foot at heel strike is in a supinated position and strikes at the lateral heel.Then the foot pronates into its midstance position.As the lower standing leg moves over the foot,the foot begins to resupinate.BY heel lift if the foot does not recover from pronation,it will continue moving into pronation.The ground force will react by dorsiflexing the 1st mpj when it should be plantarflexing and jamming of the 1st mpj will result for sure.You will see callousing on the big toe,maybe a bunion,perhaps an abductory twist of the foot in gait for pain avoidance in the 1st mpg.That is at heel lift the forefoot will slide outward[laterally] as the heel everts and drifts medially.

In my opinion...and I don't mean it to come off as dismissive or brusque...if the foot is swimming in the boot, the measurements on the last do not correspond to the measurements on the foot. I don't see how you can cut it any other way.

Pronation, flat feet, low arches...these are all separate issues. Even the dissonance between the LOMA and what the customer is actually feeling is secondary.

But on that score, as a practical matter, I think that whatever build up you need to use, it must be applied to the upper part of the medial arch area...extending into the medial heel. This will allow the foot...which wants to settle to the medial side...to do so.

Holding the foot laterally will only crowd the toes to the lateral side.

None of this addresses any medical or extreme physiological anomaly...it is only engineering.

That said, if a customer comes into my shop complaining about foot pain or other problems resulting from pronation or similar foot problems,I send him to a foot doctor.

If he is not complaining, perhaps he is like myself...I have a healthy flat foot. I say healthy because even though I have flat feet and I pronate, I have no pain and no gait problems. That's a healthy foot.

In such cases, as a boot/shoemaker...it is probably the better part of wisdom to deal with the foot as it is (as an engineering problem) and let it go at that.

Many a horse has been crippled by well meaning but unnecessary trimming.

I think your concern and questions are excellent and common to many if not all makers.

Still pondering the "LOMA" line as you say line of muscular action.What is its significance to the center of the last and toe?Could you elaborate on that LOMA phrase?I am curious of its usage since I havn`t heard of it.

DW,
In foot reflexology the entire body is re-iterated in the feet.The spine is reflected in the medial arch along with all of our bodily systems throughout the foot.
Overpronation is a problem and is not indicative of a healthy balanced foot or body.It will kinetically create problems in the lower extremity,hips,sacrum, entire spine,internal organs,endocrine and nervous systems.I believe emphatically that overpronation will effect all the myofascial and/or connective tissue throughout the body as well as the cranial wave in the dural tube between the skull and sacrum.

This may be mildly esoteric,and it is my perspective and point of view.

Many a crippled human being has been made to walk without pain and an even gait through biomechanical intervention.

I think the foot is one of evolutions engineering marvels over millions of years.And bio-mechanics vs.engineering is the link between science and art,where the shoe/bootmaker has inherent responsibilities.

Dealing with the foot as it is,is tantamount to your head in the sand.Any horse even human being,having biomechanical deficits, deserves serious consideration and a doctors prescription............I do recall your saying your position was not to accept clients with medical conditions for custom footwear as it is out of your expertise.

Brendan,
Why would Paul try a medial forefoot wedge?I think that would risk dorsiflexion of the 1st metatarsal at heel lift.And does not address collapsing of the medial arch.More then likely he is dealing with forefoot valgus and subtalor varus or valgus.I would address insuring dorsiflexing of the hallux for limitus or rigidus and plantarflexing of the 1st met at heel lift.

Paul,
I know your efforts are exceptional and sincere and I am happy if I can help you.

out of all foot shapes,Flat feet must be the hardest to fit,for a boot maker this task is even harder, on shoes the lace function,making the back seam sharper,etc will help toward a better fit,Now in Canada this sort of work is done by licensed shoe maker who are trained in it,so when they come to my shop for shoes,i tell them that i am not an orthopedic shoe maker,but willing to make them shoes and if they like the work that's fine with me,Some came back and said that their back pain is gone and some felt no pain in their feet and ordered more,but to be honest the last man that was here with flat feet and some hammer toes and God knows i tried my %110 but he was rushing me and being foolish with his tongue,now i have to somehow like my customer for everything to turn out well,I made him one pair and politely asked him to find another shoe maker for the rest of his orders.

As I was busy with yesterday, I was chewing on what you helpful friends have shared with me. And I want to Thank You all for the time you invested in your replies. (I sure wish I was a better typer, as these posts always take me so much time.)

I was thinking that, for my prespective of boot making, I adhere to the axiom "fit what's there". I'm not in business to do any correcting. I'm not making corrective footwear. I'm just trying to make good fitting boots to fullfill the customers dream. The orthopedics of it all are really beyond my scope of interest. The lingo really makes my head swim. I mean, I know I need to understand what's going on, and I try to learn from experience, I just can't wrap my head around much of the medical stuff. Take my tools away from me if I'm wrong. But heaven knows I wish "to do no harm". I just want to be the best boot maker I can be. Maybe the Pedorthics will came later.
Maybe I should have posed my quandry over in the Fitting the Foot thread, rather than here in Correcting Common Foot Problems.

So that's me, back to the customer.

Here are some pictures of what I've got and what I've done with it.

As I stated above about his fitter;
-his toes are to much to the lateral side,
-he slipped into the boots too easy, inspite of the extra reduction of 1/2" at the throat on his top pattern,
-and the instep of the fitter is way loose, inspite of the last being right on the recorded measurements.

First of all, I will be taking new measurements, to double check myself there. That's primary.

It also seems from your comments, that I should move my buildups more to the medial side, as not to allow his foot to slide out and crowd his toes. This should address my LOMA issue.

It also seems to make sence to me to move some of the buildup from the top of the cone to the bottom of the last at the arch to accomodate his very flat foot. I'm sure some of you will see something significant on his imprint, and I am open to your comments about that. The darkness down the middle of his arch on the imprint is curious.

I'm also thinking that not only will I reduce the throat an additional 1/4" or so on the top pattern, but I will also spread the tongue a bit at the quarter curve as well so as to snug up the entry there some too.

So please feel free to tell me what you think as, I truely appreciate the input from all of you.

I stand to be corrected,but how is removing buildups from top cone to the bottom will give you a good fit?the cavity of the arch on flat footed is usually filled by arch supports,soft or hard,I like the one made out of leather,now these arch supports are not going to restore fallen arches,but they help distribute the weight better in walking/standing. a well fitted shoe starts with well fitting the arch and allowing no or minimal space under the arch,but room for the toes/joints.
when taking measurements on flat feet,I also use foam to see the bottom of their feet in sitting and standing.

How is that done, Nasser, with the foam I mean? What kind of foam is it?

As to moving the fittings off of the cone and adding it underneath to the arch,
it seemed to address the customers initial comment about being very aware of the arch I had built into his fitter. I have as yet to double check the measurements and compare those against the last I built for him. But it seems like if my circumfrence is correct, then maybe the discomfort in the arch and the extra room in the instep, are a matter of the shape of my last creating the negative space for his instep rather than my measurements.

Does that make sence?

As far as I am aware this customer does not wear orthotics or arch supports. I'll ask him, of course, when I remeasure. But he mentioned none.

But I was thinking of doing an insole design such as was shown to me years ago by an old fellow from an old Utah family of shoemakers, that I worked with in a boot repair shop in Northern California. He would extend the arch area of the insole wider to encompass the arch for support, and thin and skive it to a feather. The insole was still channeled as usual as it went by the arch extension, and it continued to his breast line, as usual for a full welt. I've been thinking I could do the same thing for a 3/4 welt, such as western boots have. It might be good for my flat footed customers.

My dear friend,I think you got it right,it is the last you need to work on rather than pattern alone,if the foot is swimming in the boot,than it is the last,the pattern follows the shape of last as you well know,if the customer feels his arch is too tight,well give him more room by cutting the insole a little wider where his arch falls,but keep in mind that flat feet tend to collapse more toward the inside because of the more weight bearing of the first metatarsal,hence the the arch support to tilt the weight to the outside.
the reason for using the foam is to get a better idea what kind of a last to use and to compare the shape on weight bearing.If you need some foam,i will send you one for this costumer,if you email me your address.

First, let address the hinky part...from the photo it looks like the last is too short for the foot (might just be the angle of the shoot). You need, at minimum, three full sizes beyond the stick of the foot. More if the toe is narrow.

This alone might offer some relief to the customer on the lateral forepart.

In general...from a bootmaker's perspective, not the perspective of a foot doctor...if the foot is flat, the instep will be correspondingly low. It makes sense to me to move some of that substance under the medial arch if it is indeed needed. But if you extend your insole up into the arch, be sure, be very sure. Because the normal boot vamp will "collapse" to accommodate a flat foot but the arch cookie will not.

Looking at the photo (and I'm glad I don't have to take any real responsibility for advice made on the basis of photos) I'd also say that the build-up on the sides of the heel are too much. This may account for the roominess your customer is experiencing...or at least part of it. The featherline on the last ought to be congruent with the outline of the heelseat print but the sides of the last actually look as wide or wider than the tracing. It doesn't need to be. It's a recipe for too much.

Get your customer in a pair of trial boots...after you've checked and adjusted length, and girths, and heel width. Feel how much slack is over the instep. Feel where and how his joints align with the curves of the insole at joints. Ask your customer if he can slide his foot forward inside the boot.

If he can, it may be a sign that the long heel is too large. Putting a build up on the instep in defiance of the low instep associated with a flat foot will create a larger long heel than the foot actually has.

In the end, factoring all these elements should lead you back to the last to decrease girths and build-ups in accordance with the surplus you have observed. In some cases, that's all you can do--throw away the measurements and fit the foot as it sits in the trial boot.

Having said that, once you've achieved a reasonable fit with the trial boot....fish those measurements out of the trash and look at where you were plugging them in on the topography of the last as opposed to where the last now actually measures what the foot measures. That can tell you a lot...can teach you a lot...about where to plug measurements in on a last. It's a lesson worth learning if only for that type of specialized foot configuration.

I hope that helps...to generate some ideas if nothing else. Like I said, I'm glad it's you dealing with this foot and not me.

Paul,
Dynamic pedigraph prints will reveal more info then static prints.For instance the mid foot collapsing, loading of the forefoot and heel strike phases in gait will be clearer to you.
Your left foot print tells me that the lateral arch is flattened,the 5th met heads all but disappear with the weight moving to the 1st met head on both left and right.

Overall the medial arch cookie approach to your fitting problems is not enough.Look at the dark impression of the medial heel on that left imprint.Plus it is obvious that the 1st met head pressure is taking the forefoot load. I understand yours and others apprehensions for medial heel posting,lateral arch support or even transverse metatarsal arches.Referring clients to a medical practioner is helpful and important.

You have a customer you wan`t to make boots.There is an underlying medical condition.Your intentions are founded in "doing no harm".You have good intentions but lack the armamenture in your toolbox and you are an excellent boot maker like others.These fitting problems are agonizing and will always occur.I think there is a real key in bio mechanics and the insole,footbed,orthotic etc.Knowledge and experience are very difficult to attain.You are already engaged in fitting hard to fit feet and are asking for help.And that means a lot.So I try to help you and others ,always.

Don`t be fooled in widening your last on the medial arch.Your goal should be in balancing the entire foot in the boot.The medial,lateral and metatarsal arches may be best addressed with a cowboy boot orthotic,accomodated with the added extra depth spacer required.

Keep in mind the medial heel wedge as a starting point and ask your customers opinion on trying,just in your fitter.